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MedPAC Debates Best Way to Replace MIPS

News  |  By MedPage Today  
   November 03, 2017

Most members want MIPS repealed, but some concerned about its proposed replacement

This article first appeared November 2, 2017 on Medpage Today.

By Joyce Frieden

WASHINGTON — Although most members of the Medicare Payment Advisory Commission (MedPAC) continue to support repealing Medicare's new Merit-Based Incentive Payment System (MIPS) for physician payment, there was disagreement Thursday about what should replace it.

At a morning meeting, MedPAC staff members presented more details about a proposed replacement for MIPS called the Voluntary Value Program (VVP), and addressed concerns that commission members raised about the program at their last meeting.

MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and Meaningful Use into one single program based on quality, resource use, and clinical practice improvement. Under MIPS, doctors earn a payment adjustment based on evidence-based and practice-specific quality data that they report to the Centers for Medicare & Medicaid Services (CMS).

Issues with MIPS

But MedPAC members are concerned that MIPS will not achieve its desired goals. The flexibility of the program — the various options for how physicians can report measures and the broad exemptions for certain types of clinicians — has also made it complex. There are also statistical challenges that stem from trying to develop individual-level performance scores, due to the relatively small case sizes for some providers, David Glass, a principal policy analyst for MedPAC, told the commission during its October meeting:

"Everyone will seem to have high performance when in fact many of the measures are topped out or appear to be topped out ... and that will limit Medicare's ability to detect meaningful differences in clinician performance," he said.

And, speaking at the Thursday meeting, Glass said the program will likely cost about $1 billion in the first year, noting that the commission has raised concerns about the program for the past 2 years.

Under the VVP proposal, all clinicians would see a portion of their fee schedule dollars withheld and lumped into a pool. Clinicians could then be measured with a group of other doctors -- based on population-based outcomes, patient experience, and cost -- to be eligible for value-based incentive payments from the pool. Otherwise, they could decide to participate in an advanced alternative payment model (AAPM) program -- an option they have under the current reimbursement system, in which groups of physicians and hospitals can earn a bonus of up to 5%, based on patient outcomes, in exchange for taking on financial risk. If they chose neither of those options, they would lose all the money withheld.

One advantage of this proposal is that it would drive more clinicians to join AAPMs, Glass said, because they would be more familiar with them from the current program, and because under the VVP, they wouldn't be eligible to receive the 5% bonus that AAPMs pay for meeting quality and outcomes goals. Responding to questions raised by the commissioners, he noted that a minimum of 10 clinicians would likely be sufficient to form a VVP; currently, a third of physicians who bill Medicare work in groups that size or larger. If there isn't a group available for a particular clinician to join, CMS could establish special groups for them, Glass added.

Replacement Program Praised — With Reservations

Most commission members were on board with the VVP idea. "I'm in favor of what's written in this recommendation," said Craig Samitt, MD, MBA, executive vice president and chief clinical officer at Anthem, the big health insurer. However, Samitt expressed concern that a 10-person group would be too small to collect enough cases for meaningful quality measurement. "I worry that for metrics like readmission rates, that size would be too limited."

He also suggested encouraging the formation of specialty AAPMs. "We must accelerate and advance that opportunity so that those homes exist for specialists as much as for primary care physicians."

"I'm encouraged with the direction we're going and supportive of the overall approach," said Jack Hoadley, PhD, of Georgetown University's Health Policy Institute here. However, "it seems like the biggest issue there is risk adjustment -- if you have a group of oncologists and you're measuring the total cost of care, if it's not risk-adjusted you're not going to fare well next to the primary care practice on the other side of town. So think about [risk adjustment] or measures that don't overly penalize [providers] who see people who are [very] sick."

Brian DeBusk, PhD, of DeRoyal Industries in Powell, Tenn., said he supported MIPS repeal "but I would hope to see that specialty APMs are developed in parallel; that would take the pressure off [making the] VVP be all things to all people."

Not Everyone on Board

But not everyone was a fan. "I have very serious concerns about the VVP proposal," said David Nerenz, PhD, of the Henry Ford Health System in Detroit. "You're talking about serious social engineering in the structure of medical practice ... without compelling evidence that the structure we're talking about is good. Lots of us believe in it, but that's not the same as evidence."

In addition, "we're using the term 'voluntary,' but I don't think it's voluntary if there is a penalty for non-participation." If voluntary is what is meant, that penalty should be taken away, Nerenz said, adding that he also "doesn't think this program as proposed engages specialists in any meaningful way."

Alice Coombs, MD, of South Shore Hospital in Weymouth, Massachusetts, said she did not favor repealing the MIPS program. "MIPS has a lot of problems ... but some things coming out of it are good," she said. "I'm concerned about specialists [not participating] ... I voiced that [at the last meeting] and the answers are not appeasing for me."

She praised MIPS measures such as one for hospitals' nosocomial infection rates and another for giving patients antibiotics to cut down on infections. "Inside my world, it makes a difference," she said.

Commission chair Francis Crosson, MD, of Palo Alto, California, tried to reassure her. "I don't want you to read this proposal as MedPAC retreating from measuring surgical outcomes and the like," he said. "But we're saying that doing that at the individual doctor level for purposes of Medicare payment is probably not the appropriate direction to go in ... In terms of other entities, like hospitals ... aggressively pursuing those measures and process improvement, we're all for it."

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